Presentation on theme: "Treatment of Hypertension"— Presentation transcript:
1 Treatment of Hypertension Based on the Seventh Report of theJoint National Committee onPrevention, Detection ,Evaluation and Treatmentof High Blood Pressure (JNC-7)Jai Radhakrishnan, M.D.Division of Nephrology
2 ObjectivesDefine hypertensionPrinciples of treatmentSpecial groups
5 Why Treat Hypertension ? To decrease:Cerebrovascular Accidents %Coronary events %Heart failure %Progression of renal diseaseProgression to severe hypertensionAll cause mortality
6 Awareness, Treatment and Control of Blood Pressure 1976-2000 (NHANES)
7 Factors to Consider in Treating Hypertension Repeat readingsr/o secondary causesEstimate CV risk statusCo-morbid conditionsLifestyle changesDrugs
8 “Secondary” Hypertension Difficult to controlSudden onset of HTNWell controlled-> difficult to controlSevere hypertensionHistory/physical/labs
9 Initial Workup of Secondary HTN Renal parenchymal diseaseUA, spot urine protein/creatinine, serum creatinine, USG.RenovascularCaptopril scanCoarctationLower Extremity BPPrimary aldosteronismSerum and urinary KPlasma renin and aldosterone ratioPheochromocytomaSpot urine for metanephrine/creatinine
10 Laboratory Tests in Uncomplicated HTN ECGUrine analysisBlood glucose, hematocritBasic metabolic panelLipid profile after 9-12 hour fastUrine microalbumin
11 Estimate Risk Status Hypertension Smoking Obesity (BMI > 30kg/m2) DyslipidemiaDiabetesMicroalbuminuria or GFR <60ml/minAge > 55 (men), 65 (women)Family history of CVD(Men< 55, Women <65)Metabolic Syndrome
17 Algorithm for Treatment of Hypertension Lifestyle ModificationsNot at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)Initial Drug ChoicesStage 2 Hypertension (SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB)Stage 1 Hypertension (SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.Without Compelling IndicationsDrug(s) for the compelling indicationsOther antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.With Compelling IndicationsNot at Goal Blood PressureOptimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist.
18 Classification and Management of BP for adults BP ClassSBPDBPLifestyleInitial drug therapyWithout compelling indicationCompelling indicationsNormal<120<80EncourageNonePre-hypertension120–139or 80–89YesNo antihypertensive drug indicated.Drug(s)Stage 1 Hypertension140–159or 90–99Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.Stage 2 Hypertension>160or >100Two-drug combination (usually thiazide and ACEI or ARB or BB or CCB).*Treatment determined by highest BP category.†Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.
20 Special Considerations Compelling IndicationsSpecial populations
21 HTN with COPD and MIA 55 year old patient with COPD and HTN (controlled with nifedipine) is admitted with severe chest pain x24 hrs.BP is 170/100 and she has a soft S3 gallop.ECG shows an anterior wall MI.She is not a candidate for thrombolysis. ECHO shows an ejection fraction of 35%.How will you manage her hypertension?
22 Compelling Indications for Certain Drug Classes
23 HTN with CADBeta blockers: cardioprotective (reinfarction, arrhythmias and sudden death)ACE inhibitors: MI with systolic dysfunction- heart failure and mortality improved
24 Renal InsufficiencyA 30 year old patient with IDDM is referred with difficult-to-control HTN on diltiazem and clonidine.Exam reveals BP=190/100 and 3+ edema.Labs: Creatinine = 2.2 mg/dLSerum K = 5.1 meq/L24 hour protein = 5 g
25 Hypertension with Renal Insufficiency Goal BP <130/80ACE-inhibitors/angiotensin receptor blockers should be used if no contraindicationsMost patients have volume overload:Diuretics should be included in the regimen.Thiazides ineffective if S Creat>2.5
26 A 40 year old previously healthy male is brought to the E. R A 40 year old previously healthy male is brought to the E.R. with 3 days of progressive shortness of breath and has experienced blurred vision in both eyes.Physical exam:Blood pressure 230/140. Lethargic. Eye exam: Papilledema Chest: Bibasilar crackles Cardiac: S1S2S4 Neuro: Bilateral upgoing plantars: Extr: 2+ edemaLabs: K=3.4, BUN=35, Creatinine: 2.2CXR: Pulmonary edemaUrine: red cells, 2+ albumin.
27 Hypertensive Urgencies and Emergencies HYPERTENSIVE EMERGENCIESRequire immediate blood pressure reduction (not necessarily to normal range) to prevent or limit target organ damage.HYPERTENSIVE URGENCIESRequire reduction of blood pressure within a few hours
28 Emergencies & Urgencies HYPERTENSIVE EMERGENCIESRequire immediate blood pressure reduction (not necessarily to normal range) to prevent or limit target organ damage.HYPERTENSIVE URGENCIESRequire reduction of blood pressure within a few hours
29 Parenteral Drugs For Treatment of Hypertensive Emergencies VASODILATORSNitroprussideFenoldopamNitroglycerineEnalaprilatNicardipineHydralazineADRENERGIC INHIBITORSLabetalolEsmololPhentolamine
30 Pregnancy and Hypertension A 24 year old primiparous woman is seen in the obstetric clinic at 30 weeks gestation.BP: 160/100, 2 + pedal edemaOtherwise unremarkable physical exam.Urine shows 1000 mg of protein. Other labs: NAfter 2 days of bed rest BP remains /100
31 Drug Therapy of the Hypertensive Pregnant Patient Methyldopa: Drug of choice.Beta blockers (not early pregnancy).Hydralazine is the parenteral drug of choice.Most agents if used prior to pregnancy may be continued(except ACE-I OR A-II BLOCKERS)
32 Resistant Hypertension Improper BP measurementExcess sodium intakeInadequate diuretic therapyMedicationInadequate dosesDrug actions and interactions (e.g., nonsteroidal anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives)Over-the-counter (OTC) drugs and herbal supplementsExcess alcohol intakeIdentifiable causes of HTN
33 ConclusionsThe initial approach to hypertension should start with ruling out secondary causes, detecting and treating other cardiovascular risk factors, and looking for target organ damage.Treatment should always include lifestyle changes.Medication use should be guided by the severity of HTN and the presence of “compelling” indications.Thiazide-type diuretics should be initial drug therapy for most, either alone or combined with other drug classes.Most patients will require two or more antihypertensive drugs
34 ConclusionsHTN is a risk factor for mortality and cardiovascular and renal diseaseHTN is common but not controlled.Target BP 140/90 (130/80 in DM, CKD)Remember Compelling Indications